H.B. 347

1

PATIENT BILL OF RIGHTS
2 1999 GENERAL SESSION
3 STATE OF UTAH
4 Sponsor: Mary Carlson
5 AN ACT RELATING TO INSURANCE; CLARIFYING WHEN PREAUTHORIZATION FOR
6 EMERGENCY MEDICAL CARE MAY BE REQUIRED; ESTABLISHING A PROCESS FOR
7 STANDING REFERRALS TO A SPECIALIST AND INDEPENDENT EXTERNAL REVIEWS
8 OF ADVERSE HEALTH CARE DECISIONS; ESTABLISHING A MINIMUM BENEFIT FOR
9 PRESCRIPTION DRUGS THAT ARE EXCLUDED FROM AN INSURANCE COMPANY'S
10 FORMULARY; AND PROVIDING AN EFFECTIVE DATE.
11 This act affects sections of Utah Code Annotated 1953 as follows:
12 ENACTS:
13 31A-22-625, Utah Code Annotated 1953
14 31A-22-626, Utah Code Annotated 1953
15 31A-22-627, Utah Code Annotated 1953
16 31A-22-628, Utah Code Annotated 1953
17 Be it enacted by the Legislature of the state of Utah:
18 Section 1. Section 31A-22-625 is enacted to read:
19 31A-22-625. Coverage of emergency medical services.
20 (1) A health insurance policy or health maintenance organization contract may not:
21 (a) require any form of preauthorization for treatment of an emergency medical condition
22 until after the insured's condition has been stabilized; or
23 (b) deny a claim for any evaluation, diagnostic testing, or other treatment considered
24 medically necessary to stabilize the emergency medical condition of an insured on the ground that
25 preauthorization for the treatment was not obtained.
26 (2) (a) A health insurance policy or health maintenance organization contract may require
27 authorization for the continued treatment of an emergency medical condition after the insured's

28 condition has been stabilized.
29 (b) An insurer who does not accept or reject a request for authorization under Subsection
30 (2)(a) within an hour of receiving the request may not deny a claim for any evaluation, diagnostic
31 testing, or other treatment considered medically necessary that occurred between the time the
32 request was received and the time the insurer rejected the request for authorization.
33 (3) For purposes of this section, "emergency medical condition" means any medical
34 condition of a recent onset and severity that would lead a prudent layperson, possessing an average
35 knowledge of medicine and health, to believe that the person's condition, sickness, or injury was
36 of such a nature that the failure to obtain immediate medical care could result in:
37 (a) placing the insured's health in serious jeopardy;
38 (b) serious impairment to bodily functions; or
39 (c) serious dysfunction of any bodily organ or part.
40 Section 2. Section 31A-22-626 is enacted to read:
41 31A-22-626. Standing referral to a specialist.
42 (1) An insurer who does not allow direct access to a health care specialist shall establish
43 and implement a procedure by which an insured may obtain a standing referral to a health care
44 specialist.
45 (2) The procedure established under Subsection (1):
46 (a) shall provide for a standing referral to a specialist if the insured's primary care provider
47 determines, in consultation with the specialist, that the insured needs continuing care from the
48 specialist; and
49 (b) may require the approval of the insurer, in consultation with the insured, the primary
50 care provider, and the specialist, of a treatment plan, which may include:
51 (i) a limit on the number of visits to the specialist;
52 (ii) a time limit on the duration of the referral; and
53 (iii) mandatory updates on the insured's condition.
54 Section 3. Section 31A-22-627 is enacted to read:
55 31A-22-627. Independent external review of health care service decisions.
56 (1) An insured who has exhausted all applicable internal review procedures under a health
57 insurance policy or health maintenance organization contract may seek an independent external
58 review of a decision of the insurer to deny, reduce, or terminate coverage or to deny payment for

59 a health care service if:
60 (a) the insured requests the external independent review in writing;
61 (b) the amount at issue exceeds $100; and
62 (c) the decision of the insurer is based on one of the following reasons:
63 (i) the treatment was not medically necessary;
64 (ii) the treatment was not provided by an appropriate health care provider;
65 (iii) the treatment was experimental, investigational, or involved an off-label drug; or
66 (iv) the treatment was for a preexisting condition.
67 (2) The department shall adopt rules necessary to carry out the purposes of this section and
68 to ensure that:
69 (a) an independent external review be conducted:
70 (i) by a panel approved by the department that includes a health care provider and
71 members without conflicts of interest;
72 (ii) in accordance with standards of decision-making based on objective clinical evidence;
73 and
74 (iii) in a timely manner with special attention given to resolving decisions involving
75 emergency or urgent health care services;
76 (b) an insured:
77 (i) is given adequate notice of review rights under this section;
78 (ii) is informed of the right to use outside assistance during the review process and to
79 submit relevant evidence;
80 (iii) pays a processing fee of not more than $25; and
81 (iv) is protected against retaliation for exercising review rights under this section;
82 (c) a written decision of the panel is issued to both the insured and the insurer; and
83 (d) health care information is maintained in accordance with state and federal law.
84 (3) Except as provided in Subsection (2)(b)(iii), an insurer shall pay for the cost of an
85 independent external review.
86 Section 4. Section 31A-22-628 is enacted to read:
87 31A-22-628. Minimum benefit coverage for nonformulary prescription drugs.
88 (1) This section applies generally to all health insurance policies and health maintenance
89 organization contracts.

90 (2) Consistent with Subsection (3), an insurer who offers a prescription drug benefit may
91 establish a formulary and may determine which prescription drugs to include on or exclude from
92 the formulary.
93 (3) An insurer who establishes a formulary shall provide a minimum benefit for medically
94 necessary, federal Food and Drug Administration-approved prescription drugs that are excluded
95 from the formulary. The minimum benefit shall be no less than 75% of the amount the insurer
96 would have to pay under the policy or contract for the most expensive comparable prescription
97 drug, not to exceed the benefit amount the insurer would have to pay if the prescription drug were
98 included on the formulary.
99 (4) An insurer shall pay a claim submitted under Subsection (3) within 20 days of
100 receiving the necessary information to process the claim.
101 (5) An insurer shall include an explanation of this section in the written materials it is
102 required to give an enrollee, prior to enrollment, on prescription drug coverage and limitations
103 under Subsection 31A-22-613.5 (9).
104 (6) The commissioner shall encourage and work with insurers to make formulary
105 information available on the Internet.
106 (7) As used in this section:
107 (a) "comparable prescription drug" means a prescription drug that has the equivalent
108 dosage and for which there is general consensus within the medical community that it treats the
109 same medical condition as another prescription drug;
110 (b) "necessary information" may include the medical opinion of the insured's physician;
111 and
112 (c) "pay" means a direct payment to a vendor of a nonformulary prescription drug or a
113 direct reimbursement to an insured who purchased a nonformulary prescription drug.
114 Section 5. Effective date.
115 This act takes effect on July 1, 1999.

Legislative Review Note
as of 2-16-99 2:15 PM

A limited legal review of this legislation raises no obvious constitutional or statutory concerns.

Office of Legislative Research and General Counsel